Screening preschool children for fine motor
skills: environmental influence
Nilay Comuk-BalCi, PT, PhD1)*, Birgul Bayoglu, MSD2), agah TekiNdal, PhD3), miNTaze kerem-guNel, PT4), BaNu aNlar, MD5)
1) Department of Physiotherapy and Rehabilitation, Baskent Univeristy: 06810 Etimesgut, Ankara,Turkey
2) Ihsan Dogramaci Child Development Unit, Hacettepe University, Turkey 3) Department of Biostatistics and Medical Informatics, Izmir University, Turkey 4) Department of Physiotherapy and Rehabilitation, Hacettepe University, Turkey 5) Department of Pediatric Neurology, Hacettepe University, Turkey
Abstract. [Purpose] The aim of this study was to investigate the influence of gender and family factors on perfor-mance in the fine motor domain of the Denver II developmental screening test. [Subjects and Methods] Data were obtained from 2038 healthy children, 999 boys (49%) and 1039 girls (51%) in four age groups: 0–24 months (57%), 25–40 months (21.1%), 41–56 months (10.4%), and 57–82 months (11.5%). [Results] Female gender, higher maternal age, especially in children older than 24 months, and higher maternal education were associated with earlier accom-plishment of fine motor items. Higher socioeconomic status was correlated with fine motor skills more noticeably at young ages. [Conclusion] The results of this study support the role of environmental factors in the interpretation of fine motor test results and point to target groups for intervention, such as infants in the low socioeconomic group and preschool children of less educated mothers. Studies in different populations may reveal particular patterns that affect child development.
Key words: Development, Socioeconomic, Maternal educational status
(This article was submitted Nov. 10, 2015, and was accepted Dec. 15, 2015)
INTRODUCTION
Neurologic development during infancy and childhood depends on physical health and genetic disposition, and progresses under the influence of the social context and environment1). To perform activities in daily life, motor process and social interaction skills are required. Motor development is based on actions that a person enacts when interacting with and moving task objects and themselves around a task environment2, 3). Among environmental factors, home and family play a primary role during early childhood years. Parental education, socioeconomic status, family size, and interaction with siblings are main elements of a child’s close environment4). Fine motor development affects other areas of development, and in particular, school performance in later childhood. Despite their importance, age-appropriate fine motor abilities are seldom questionedor evaluated in pediatric clinics: often, physicians ask parents or caregivers about the child’s language and gross motor abilities, and observe social and gross motor functions during physical examination. Developmental screening tests, despite their high reliability and interest agreement, are used only by 60% of U.S. physicians, a rate likely to be lower in many other countries5, 6). To interpret any observations or test results, health professionals should be familiar with normal development and influencing factors, and recognize the nature and extent of external influences so that delays due to medical and treatable conditions are not erroneously attributed to adverse environmental factors. Therefore, the aim of this study was to investigate the effect of socioeconomic and maternal factors on the fine motor development of healthy children.J. Phys. Ther. Sci. 28: 1026–1031, 2016
*Corresponding author. Nilay Comuk-Balci (E-mail: nlycmk@yahoo.com) ©2016 The Society of Physical Therapy Science. Published by IPEC Inc.
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License <http://creativecommons.org/licenses/by-nc-nd/4.0/>.
Original Article
The Journal of Physical Therapy Science
The Journal of Physical Therapy Science
SUBJECTS AND METHODS
Data were obtained from 2,038 healthy children aged 0–82 months, 999 boys (49%) and 1,039 girls (51%) in four age groups: 0–24 months (57%), 25–40 months (21.1%), 41–56 months (10.4%), and 57–82 months (11.5%). Children with a history of preterm delivery, birth weight <2,500 g, hospitalization, congenital malformation or current illness were excluded. Demographic data collected by using a standard questionnaire included the following: • Mother’s age: stratified as 20≤, 21–25, 26–30, 31–39, and 40≥ years; • Mother’s education: no education, up to 8 years’ schooling, 8–12 years schooling, and ≥12 years; • Number of children at home; • Area of residence within the district of Ankara, indicating three different socioeconomic groups (SEG) as identified by the Turkish Institute of Statistics: high, middle, and low SEG7).The developmental items commonly used in outpatient evaluation were retrieved from the Denver II developmental screening test. The Denver II version standardized for Turkey was applied by trained child development specialists or a pediatric neurologist. The test contains total 134 items in four developmental domains: personal-social, fine motor, language, and gross motor. The result is scored as “normal” when there is no delay in any items. The fine motor section of Denver II contains 33 items8). Inter tester and intra tester reliability were assessed by testers watching video recordings of 20 children at 4 weeks’ interval and scoring separately, and were >90% throughout the data collection. Only children with normal test results were included in this study, and the mean age at which they passed each fine motor item was calculated. This study was conducted by Ihsan Doğramaci Childrens’ Hospital and the Department of Pediatric Neurology of Hacette-pe University, Ankara, Turkey. Ethical approval was obtained from the ethics committee of Hacettepe University Faculty of Medicine. The data were collected after informed parental consent was received. The effect of demographic and maternal factors on fine motor items was assessed for each age group. The results of tests were expressed as the number of observations (n), mean (X) ± standard deviation (SD). Homogeneity (Levene’s) and normality (Shapiro Wilk) tests were used to choose statistical methods. Groups with normal distribution and homogeneous variances were assessed by using Pearson’s correlation coefficient. As parametric test assumptions were not available for some variables, these were assessed by using Spearman rho correlation coefficient. All statistical analyses were performed with the SPSS software (SPSS ver. 17.0; SPSS Inc., Chicago IL, USA), and p<0.05 was considered statistically significant.
RESULTS
The demographic characteristics of children are shown in Table 1, and those of mothers in Table 2. The number of boys and girls were similar. Most children were from middle SEG and most mothers’ educational level was high school (8–12 years). Forty-eight percent of households contained only one child.
The factors affecting fine motor items were gender, mother’s age and education, SEG, and number of siblings. Girls acted at earlier ages in grasping a rattle (Table 3), copying a circle (Table 4), copying a square (Table 5), and drawing a man of six parts (Tables 5 and 6).
The mother’s age was influential on several items in all age groups, most markedly in older children (>57 months) (Tables 3–6). As the mother’s age increased, the fine motor skills of the children were acquired earlier. The mother’s educational level was associated with earlier acquisition of fine motor items, mostly in children older than 24 months (Tables 3–6). SEG was positively correlated with fine motor skills before 56 months, most markedly in the first 6 months of life (Tables 3–6). The number of children at home was not effective; however, it showed a negative correlation with one fine motor skill between 41 and 56 months: copying a square (Table 5).
DISCUSSION
Fine motor functions carry great biological importance for humans, as reflected by the large cortical representation of the hands in the cerebral cortex. Fine motor skills correlate with cognitive test results, partly because of their part in psychometric testing and partly because they allow the child to experiment and learn about the environment9, 10). On the other hand, they are less well recognized by parents who usually are more aware of gross motor milestones and more often concerned with delays in gross motor skills11). Factors likely to affect fine motor skills must be known to plan interventions in children at a risk for delayed development. The present study analyzed fine motor development with respect to environmental factors in the population, namely, mother’s age and education, socioeconomic status, and number of children in the household. The overall effect of gender was modest, with girls starting earlier in certain fine motor skills of various ages. Similarly, Nordberg et al.12) found that girls had higher scores in eye-hand coordination on Griffiths development scales at 4 years of age. Flatters et al.13) reported that girls were more likely to have superior manual control in aiming and tracing tasks at school age. Other studies also showed girls out performing boys on manual dexterity, especially in pencil- and paper-based skills14–16). It is plausible that fine motor maturationis completed at a later age in boys. The quality of the family environment has been associated with the intellectual and motor development of the familymembers16). SEG affects the home environment, opportunities for educational and play activities, and therefore gross and
fine motor performance8). Certain studies observed the influence of social class on a child’s development after 1 year17) and
at 3 and 5 years of age18), while others demonstrated the effect of cultural factors, home environment, and SEG on fine motor
development in 9-month-old children and during the first 18 months of life10, 19). Our results also show that the effect of SEG begins from early infancy. Children of low SEG tend to show delays on several motor development assessment batteries, although certain reports point to earlier achievement of gross motor milestones than in children from higher SEG20–22). Perceptual-motor problems of children with lower environmental resources may be related to poor nutrition, poor health care, or lack of stimulation and opportunities for experience. The effect of maternal education may involve higher intellectual level, positive psychology, or higher income resulting in increased opportunities for the child. Jackson et al.23) observed fewer behavioral problems and improved preschool motor development in children of single-parent families with higher maternal education. Higher social class and maternal education was found to be related to psychomotor performance in children >1 year of age17, 23) and low maternal education, after the age of 2 or 3 years24, 25). Our findings are consistent with these studies: the positive effect of the mother’s education was observed mostly in children >24 months of age. The mother’s age had a modest effect from late infancy through childhood, which is less marked than the mother’s education. Table 1. Demographic characteristics of children n % Age (months) 25–400–24 1,136420 57.021.1 41–56 208 10.4 57–82 229 11.5 Gender Girl 1,039 51.0 Boy 999 49.0 Number of children at home 1 999 48.8 2 713 34.8 3 205 10.0 4≥ 55 6.4 Min Max X±SD Age (months) 0.3 82 24.9±20.5 Height (cm) 50 135 84.1±20.5 Weight (kg) 1.6 30.8 11.9±5.5 Head circumference (cm) 34 58 46.4±4.3 Table 2. Demographic characteristics of mothers n % Age (years) <20 107 5.3 21–25 496 24.6 26–30 683 33.8 31–39 646 32.0 40≥ 86 4.3 Education No education 37 1.8 1–8 years 722 36.0 8–12 years 764 38.1 >12 years 483 24.1 Socioeconomic
group MiddleLow 806519 40.225.9
High 651 32.5 Min Max X±SD Age (years) 16 53 28.8±5.5 Table 3. Factors affecting fine motor skills at 0–24 months of age Follows past midline Grasps a rattle Follows 180° Reaches for objects Looks for ayarn Transfers blocks from hand to hand Takes two blocks Bangs two blocks together Places cube in a cup Scribbles sponta-neously Dumps raisin from bottle— demonstrated Dumps raisin from bottle— spontaneous Gender r 0.090* 0.002 0.004 0.001 0.029 0.020 0.122 0.040 0.002 0.050 0.039 0.036 Mother’s age r 0.049 0.066 0.080 0.029 0.069 0.023 −0.225* 0.134* 0.090* 0.151* 0.092* 0.071 Mother’s education r 0.037 0.087 0.048 0.049 0.081 0.018 0.024 0.082 0.015 0.068 0.003 0.094* Socio-economic group r 0.217* 0.187* 0.153* 0.181* 0.093* 0.117* 0.155 0.070 0.139* 0.025 0.153* 0.176* Number of children at home r 0.001 0.027 0.008 0.007 0.058 0.031 0.058 0.044 0.017 0.002 0.037 0.017 Significant p values are in bold. *p<0.05
Older siblings may serve as models for fine motor tasks and provide encouragement to their younger siblings. However, siblings may also fail to elicit a positive interaction. Our study did not show a considerable influence of the number of children at home: if at all, the correlation with fine motor skills was negative. This may be explained by the division of parental attention as suggested by “dilution of parental resources” or fewer opportunities for the young child’s fine motor experience26). Alvik27) also demonstrated the presence of an older sibling to be associated with reduced scores in the Ages
and Stages Questionnaire, a parent-completed screening instrument for children <5.5 years old. Our study is based on items used in clinics for developmental screening because our aim was to offer recommendations for pediatric outpatient and well-baby clinics caring for children on a day-to-day basis. Research on developmental patterns and their neurobiological basis require more detailed tests. Fine motor problems are an important part of developmental coordination disorder (DCD), a term defining a neuromotor disability where motor difficulties (lower speed, lower accuracy) interfere with daily life or school activities. Motor control and muscle strength impairments are the primary reasons for motor behavior disorders28). DCD affects about 5% of school-age children29). Whether the diagnosis of DCD can be predicted by
screening for early fine motor skills, and whether the severity of DCD may be reduced by means of intervention on influenc-ing factors constitute interesting areas to explore30).In addition, attention-deficit hyperactivity disorder (ADHD) is a common
neurodevelopmental disorder that affects 3–7% of preschool and school-aged children. It has been suggested that the deficits of ADHD children in memory performance, and the inability to allocate sufficient attention to postural control may contribute to the trend of further deteriorating fine motor skills with postural balance31, 32). Lee et al.33)
suggested that complex interac-tions between multiple risk factors such as physical fitness levels of children are responsible for ADHD.
In conclusion, sex and environmental and maternal factors appear influential in the development of fine motor skills in
Table 6. Factors affecting fine motor skills at 57–82 months old
Copies circle Copies cross Copies square demonstrated Copies square
Draws man and parts Child’s gender r 0.022 0.010 0.072 0.019 0.231* Mother’s age r 0.235* 0.217* 0.233* 0.165* 0.117 Mother’s education r 0.200* 0.334* 0.350* 0.309* 0.309 Socioeconomic Status r 0.057 0.126 0.085 0.038 0.232* Number of children at home r 0.125 0.034 0.008 0.012 0.054 Significant p values are in bold. *p<0.05 Table 5. Factors affecting fine motor skills at 41–56 months old
Copies a circle Copies a cross Copies a square square—demon-Copies a strated Draws a man of six parts Child’s gender r 0.131 0.121 0.140* 0.122 0.240* Mother’s age r 0.043 0.073 0.068 0.020 0.081 Mother’s education r 0.063 0.184* 0.172* 0.133 0.105 Socioeconomic status r 0.206* 0.226* 0.134 0.147* 0.206* Number of children at home r 0.136 0.051 −0.152* 0.084 0.102 Significant p values are in bold. *p<0.05 Table 4. Factors affecting fine motor skills at 25–40 monthsold
Copies a circle Draws a man of three parts
Child’s gender r 0.209* 0.027 Mother’s age r 0.156* 0.123* Mother’s education r 0.179* 0.123* Socioeconomic status r 0.137* 0.070 Number of children at home r 0.056 0.120* Significant p values are in bold. *p<0.05
early life. These first years are a period of intense biological maturation likely to shape the architecture of the central nervous system. Negative environmental factors increase the developmental risk brought by adverse medical conditions such as prematurity34). On the other hand, those children at risk may benefit from reinforcement of positive factors: interventions may overcome the effect of adverse perinatal events35, 36). The findings of our study may help the planning of interventions, such as providing additional preschool education for children from disadvantaged economic and maternal education groups, and can also contribute to the planning of research projects with matching intervention and control groups.
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